====== Perindopril ======

Perindopril is a long-acting ACE inhibitor used in hypertension and stable coronary artery disease.

It has strong outcome data in vascular disease populations.

Class:
→ [[cardio:raas:acei|ACE Inhibitors]]

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===== Mechanism of Action =====

• Inhibits Angiotensin-Converting Enzyme (ACE)
• ↓ Angiotensin II
• ↓ Aldosterone
• ↑ Bradykinin

Net Effects:
• ↓ Systemic vascular resistance
• ↓ Blood pressure
• ↓ Ventricular remodeling
• ↓ Vascular inflammation

Mechanism identical to other ACE inhibitors.

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===== Unique Features =====

• Prodrug → converted to perindoprilat
• Long-acting (once-daily dosing)
• Strong evidence in stable coronary artery disease (EUROPA trial)
• Stroke risk reduction data (PROGRESS trial)

More commonly used in Europe than the United States.

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===== Indications =====

==== Hypertension ====
• Effective once-daily ACE inhibitor

→ [[cardio:hypertension:start|Hypertension Module]]

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==== Stable Coronary Artery Disease ====
• Reduces cardiovascular events (EUROPA trial)
• Vascular protection in high-risk patients

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==== Stroke Prevention (High-Risk Patients) ====
• Reduced recurrent stroke risk (PROGRESS trial)

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==== Heart Failure (HFrEF) ====
• Used similarly to other ACE inhibitors
• Mortality benefit expected as class effect

→ [[cardio:heart_failure:start|Heart Failure Module]]

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===== Dosing =====

Hypertension:
• Start: 4 mg once daily
• Usual range: 4–8 mg once daily

Stable CAD:
• Typically titrated to 8 mg daily (if tolerated)

Once-daily dosing.

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===== Pharmacokinetics =====

• Prodrug → activated in liver
• Renally cleared
• Long half-life of active metabolite (~25–30 hours)

Dose adjustment required in renal impairment.

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===== Adverse Effects =====

Class Effects:
• Dry cough
• Hyperkalemia
• Hypotension
• Angioedema (rare)
• Mild creatinine elevation

No major pharmacologic difference from other ACE inhibitors.

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===== Monitoring =====

Monitor:
• Serum creatinine
• Potassium

Check labs 1–2 weeks after initiation or dose adjustments.

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===== Contraindications =====

• Pregnancy
• History of ACE inhibitor–induced angioedema
• Bilateral renal artery stenosis

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===== Clinical Pearls =====

✔ Long-acting ACE inhibitor  
✔ Strong vascular protection data (EUROPA)  
✔ Stroke reduction data (PROGRESS)  
✔ More commonly used outside the U.S.  
✔ Once-daily dosing  

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Related:

→ [[cardio:raas:acei|ACE Inhibitors]]
→ [[cardio:raas:ramipril|Ramipril]]
→ [[cardio:heart_failure:start|Heart Failure Module]]
→ [[cardio:start|Return to CV Modules]]